Evidence-based psychological interventions for adults with chronic pain: precision, control, quality, and equipoise

Current state of psychological therapies for children and adults with chronic pain: Where next?

Pain is influenced by biological, psychological and social factors. Whilst analgesics are often prescribed for chronic pain, they provide little benefit for most patients. Psychological therapies manage pain and disability in children and adults with chronic pain. Evidence for cognitive behavioural therapies is the most robust in the field, although benefits are modest. Technological innovation has led to Internet-delivered therapies, but innovation in research often lags behind technological developments due to funding and regulation. Despite the promising outlook, critical gaps in our knowledge of how to manage pain need addressing for both adults and children and their parents. Here we summarise the evidence base of psychological therapies using Cochrane reviews, gaps, and the role of preventing chronic pain onset.

Comparative main effects, mediators, and moderators of cognitive behavioral therapy, acceptance and commitment therapy, and emotional awareness and expression therapy for chronic spinal pain: Randomized controlled trial rationale and protocol

Background

Chronic spinal (back/neck) pain is common and costly. Psychosocial treatments are available but have modest effects. Knowledge of treatment mechanisms (mediators and moderators) can be used to enhance efficacy. Trials that directly compare different treatments are needed to determine which mechanisms are treatment-specific, which are shared across treatments, and which contribute the most to outcomes.

Methods

We will conduct a 4-arm randomized, controlled clinical trial to compare the main effects, mediators, and moderators of three pain therapies: Cognitive-Behavioral Therapy, Acceptance and Commitment Therapy, and Emotional Awareness and Expression Therapy in adults with chronic spinal pain. Following baseline assessment of outcomes variables (two primary outcomes: pain intensity and pain interference) and potential mediators and moderators, we will randomize participants (up to 460) to one of the treatments or usual care control. Treatments will be conducted individually each week for 8 weeks via telehealth. We will conduct weekly assessments of both potential mediators and outcomes, as well as post-treatment and 6-month follow-up assessments. We will test whether any of the therapies is superior to the others (Aim 1); identify mediators that are specific to treatments and those that are shared across treatments (Aim 2); and identify baseline moderators that are specific to treatments or shared across treatments, and moderated mediators of treatments (Aim 3).

Discussion

The findings from this project can be used to improve the effects of psychosocial chronic pain treatments by identifying the most powerful specific and shared mechanisms and revealing for whom the mediator-outcome pathways are strongest.

Analgesic effects of non-surgical and non-interventional treatments for low back pain: a systematic review and meta-analysis of placebo-controlled randomised trials

OBJECTIVES

To investigate the efficacy of non-surgical and non-interventional treatments for adults with low back pain compared with placebo.

ELIGIBILITY CRITERIA

Randomised controlled trials evaluating non-surgical and non-interventional treatments compared with placebo or sham in adults (≥18 years) reporting non-specific low back pain.

INFORMATION SOURCES

MEDLINE, CINAHL, EMBASE, PsychInfo and Cochrane Central Register of Controlled Trials were searched from inception to 14 April 2023.

RISK OF BIAS

Risk of bias of included studies was assessed using the 0 to 10 PEDro Scale.

SYNTHESIS OF RESULTS

Random effects meta-analysis was used to estimate pooled effects and corresponding 95% confidence intervals on outcome pain intensity (0 to 100 scale) at first assessment post-treatment for each treatment type and by duration of low back pain-(sub)acute (<12 weeks) and chronic (≥12 weeks). Certainty of the evidence was assessed using the Grading of Recommendations Assessment (GRADE) approach.

RESULTS

A total of 301 trials (377 comparisons) provided data on 56 different treatments or treatment combinations. One treatment for acute low back pain (non-steroidal anti-inflammatory drugs (NSAIDs)), and five treatments for chronic low back pain (exercise, spinal manipulative therapy, taping, antidepressants, transient receptor potential vanilloid 1 (TRPV1) agonists) were efficacious; effect sizes were small and of moderate certainty. Three treatments for acute low back pain (exercise, glucocorticoid injections, paracetamol), and two treatments for chronic low back pain (antibiotics, anaesthetics) were not efficacious and are unlikely to be suitable treatment options; moderate certainty evidence. Evidence is inconclusive for remaining treatments due to small samples, imprecision, or low and very low certainty evidence.

CONCLUSIONS

The current evidence shows that one in 10 non-surgical and non-interventional treatments for low back pain are efficacious, providing only small analgesic effects beyond placebo. The efficacy for the majority of treatments is uncertain due to the limited number of randomised participants and poor study quality. Further high-quality, placebo-controlled trials are warranted to address the remaining uncertainty in treatment efficacy along with greater consideration for placebo-control design of non-surgical and non-interventional treatments.

TRIAL REGISTRATION NUMBER

OSF Registries; https://osf.io/2dk9z.

An Interdisciplinary Multimodal Integrative Healthcare Program for Chronic Spinal Pain and Comorbid Mental Disorders

OBJECTIVE

Previous studies evaluating interdisciplinary multimodal interventions for chronic spinal pain often excluded patients with comorbid mental disorders. This study aims to assess the effectiveness of an outpatient secondary care interdisciplinary multimodal integrative healthcare program for individuals experiencing co-occurring chronic spinal pain and mental disorders.

METHODS

Participants were 944 patients with chronic spinal pain and comorbid mental disorders. Primary outcomes were health-related quality of life, assessed using the Research and Development-36 (RAND-36), and pain-related disability, assessed using the Quebec Back Pain Disability Scale (QBPDS). Secondary outcomes included pain intensity, pain catastrophizing, kinesiophobia, fatigue, lumbar mobility, and isometric strength. Data were collected during the healthcare program at four time points: pretreatment (T0), midway through 20-week treatment (T1), end of 20-week treatment (T2), and at completion of 12-month relapse prevention program (T3). Multilevel regression analyses were conducted to examine the effects of the healthcare program on primary outcomes over time.

RESULTS

The 20-week treatment period yielded significant improvements in both mental ( B = 0.44, t (943) = 19.42, p < .001) and physical component summary scores ( B = 0.45, t (943) = 18.24, p < .001) of the RAND-36, as well as in QBPDS total score ( B = -0.77, t (943) = -26.16 p < .001). Pretreatment scores indicated the presence of problematic fatigue, kinesiophobia, and clinical levels of pain catastrophizing, all of which resolved by the end of the 12-month relapse prevention program.

CONCLUSIONS

An interdisciplinary multimodal integrative healthcare program seems effective for patients with chronic spinal pain and comorbid mental disorders.

Exercise combined with Acceptance and Commitment Therapy for chronic pain: One-year follow-up from a randomized controlled trial

BACKGROUND

Acceptance and Commitment Therapy (ACT) is a type of Cognitive Behavioural Therapy, which has demonstrated positive outcomes in individuals with chronic pain. The purpose of this study was to compare the effect of an 8-week programme combining Exercise with Acceptance and Commitment Therapy (ExACT) with a standalone supervised exercise programme at 1-year follow-up.

METHODS

One hundred and seventy-five people with chronic pain were randomly assigned to ExACT or supervised exercise only. The primary outcome was pain interference measured with the Brief Pain Inventory-Interference Scale. Secondary and treatment process outcomes included pain severity, depression, anxiety, pain catastrophizing, pain self-efficacy, fear avoidance, pain acceptance, committed action, healthcare utilization, patient satisfaction, and global impression of change. Estimates of treatment effects at 1-year follow-up were based on intention-to-treat analyses, implemented using a linear mixed-effects model.

RESULTS

Eighty-three participants (47.4%) returned the outcome measures at 1-year follow-up. No significant difference was observed between the groups for the primary outcome, pain interference. There was a statistically significant difference between the groups, in favour of ExACT for pain catastrophizing. Within group improvements that were observed within both groups at earlier timepoints were maintained at 1-year follow-up for many of the secondary and treatment process outcomes. ExACT group participants reported higher levels of satisfaction with treatment and global perceived change.

CONCLUSIONS

The study results showed no significant difference between the two groups for the primary outcome pain interference at 1-year follow-up. Future research could investigate factors that may predict and optimize outcomes from these types of intervention for people living with chronic pain.

SIGNIFICANCE

Few previous randomized controlled trials investigating ACT for chronic pain have included long-term follow-up. This study found that Exercise combined with ACT was not superior to supervised exercise alone for reducing pain interference at 1-year follow-up. Further research is necessary to identify key processes of therapeutic change and to explore how interventions may be modified to enhance clinical outcomes for people with chronic pain.

Associations between Degenerative Lumbar Scoliosis Structures and Pain Distribution in Adults with Chronic Low Back Pain

BACKGROUND

This study aimed to investigate the location and distribution of pain in adults with chronic low back pain (LBP) with degenerative lumbar scoliosis (DLS) according to coronal deformities.

METHODS

We enrolled 100 adults with chronic LBP and DLS, dividing them into two groups, a right-convex DLS group (n = 50) and a left-convex DLS group (n = 50). Dominant pain location was analyzed by dividing it into three parts-left side, right side, and center-and pain areas were identified using the pain drawing method; then, a heat map was created for each group. An association between pain location and convex side was analyzed as the primary outcome. Additionally, we assessed pain characteristics and radiological parameters, such as the curve structure and degree of degeneration. We used the Mann-Whitney U test or the chi-squared test to compare the clinical characteristics of the two groups, and generalized linear models were utilized to determine which variables were associated with pain severity or pain area.

RESULTS

The results indicated that there was no significant difference between the two groups in terms of the association between the curve structure, pain severity and location. In multivariate analysis, although we did not find any variables associated with pain severity, we observed that age and a left-convex DLS were negatively correlated with pain area among all participants. The heat map demonstrated that individuals with chronic LBP frequently experienced pain in the central lumbar region, regardless of the coronal curve structure.

CONCLUSIONS

Our findings suggest that degenerative coronal lumbar deformities may not have a specific pain pattern associated with a curved structure.

Efficacy of interventions to reduce long term opioid treatment for chronic non-cancer pain: systematic review and meta-analysis

OBJECTIVE

To review interventions to reduce long term opioid treatment in people with chronic non-cancer pain, considering efficacy on dose reduction and discontinuation, pain, function, quality of life, withdrawal symptoms, substance use, and adverse events.

DESIGN

Systematic review and meta-analysis of randomised controlled trials and non-randomised studies of interventions.

DATA SOURCES

Medline, Embase, PsycINFO, CINAHL, and the Cochrane Library searched from inception to July 2021. Reference lists and previous reviews were also searched and experts were contacted.

ELIGIBILITY CRITERIA FOR STUDY SELECTION

Original research in English. Case reports and cross sectional studies were excluded.

DATA EXTRACTION AND SYNTHESIS

Two authors independently selected studies, extracted data, and used the Cochrane risk-of-bias tools for randomised and non-randomised studies (RoB 2 and ROBINS-I). Authors grouped interventions into five categories (pain self-management, complementary and alternative medicine, pharmacological and biomedical devices and interventions, opioid replacement treatment, and deprescription methods), estimated pooled effects using random effects meta-analytical models, and appraised the certainty of evidence using GRADE (grading of recommendations, assessment, development, and evaluation).

RESULTS

Of 166 studies meeting inclusion criteria, 130 (78%) were considered at critical risk of bias and were excluded from the evidence synthesis. Of the 36 included studies, few had comparable treatment arms and sample sizes were generally small. Consequently, the certainty of the evidence was low or very low for more than 90% (41/44) of GRADE outcomes, including for all non-opioid patient outcomes. Despite these limitations, evidence of moderate certainty indicated that interventions to support prescribers' adherence to guidelines increased the likelihood of patients discontinuing opioid treatment (adjusted odds ratio 1.5, 95% confidence interval 1.0 to 2.1), and that these prescriber interventions as well as pain self-management programmes reduced opioid dose more than controls (intervention v control, mean difference -6.8 mg (standard error 1.6) daily oral morphine equivalent, P<0.001; pain programme v control, -14.31 mg daily oral morphine equivalent, 95% confidence interval -21.57 to -7.05).

CONCLUSIONS

Evidence on the reduction of long term opioid treatment for chronic pain continues to be constrained by poor study methodology. Of particular concern is the lack of evidence relating to possible harms. Agreed standards for designing and reporting studies on the reduction of opioid treatment are urgently needed.

REVIEW REGISTRATION

PROSPERO CRD42020140943.

Not really nice: a commentary on the recent version of NICE guidelines [NG193: chronic pain (primary and secondary) in over 16s: assessment of all chronic pain and management of chronic primary pain] by the Pain Net

The National Institute for Health and Care Excellence provides evidence-based advice that guides clinical practice. We highlight major criticisms related to the new guideline for chronic primary pain.

The National Institute for Health and Care Excellence should revise their recent guideline to take into account all the available evidence on the treatment of chronic primary pain.